Inspection Reports for AMS Memorial-Greene
108 South High Street, IA, 506360617
Back to Facility ProfileInspection Report Summary
The most recent inspection on April 13, 2022, found the facility in compliance based on acceptance of a plan of correction following prior deficiencies. Earlier inspections identified issues mainly related to medication management, care planning, staffing qualifications, and infection control. Prior reports cited deficiencies in developing comprehensive person-centered care plans, proper use and monitoring of psychotropic medications, and ensuring adequate RN coverage and CPR-certified staff. Complaint investigations were not listed in the available reports. The facility’s record shows improvement over time, with the most recent inspection confirming compliance after addressing earlier concerns.
Deficiencies (last 2 years)
Deficiencies (over 2 years)
8 deficiencies/year
Deficiencies are regulatory violations found during state inspections.
82% worse than Iowa average
Iowa average: 4.4 deficiencies/yearDeficiencies per year
8
6
4
2
0
Census
Latest occupancy rate
19 residents
Based on a March 2022 inspection.
This facility has shown a decline in demand based on occupancy rates.
Census over time
Inspection Report
Plan of Correction
Deficiencies: 0
Date: Apr 13, 2022
Visit Reason
The document serves as a plan of correction following a prior inspection, indicating acceptance of the facility's credible allegation of compliance.
Findings
The facility was certified in compliance effective April 13, 2022, based on acceptance of the plan of correction and credible allegation of compliance.
Inspection Report
Re-Inspection
Census: 19
Deficiencies: 2
Date: Mar 31, 2022
Visit Reason
The visit was an onsite revisit conducted on 3/30/22 - 3/31/22 regarding the recertification survey conducted on 2/14/22 - 2/21/22.
Findings
The facility failed to develop a comprehensive person-centered care plan related to the use of a high-risk medication for 1 of 5 residents reviewed and failed to ensure a PRN medication order for an anti-anxiety drug was limited to 14 days with proper physician documentation for continuation for 1 of 4 residents reviewed.
Deficiencies (2)
Failed to develop a comprehensive person-centered care plan related to the use of a high-risk medication (Coumadin) for Resident #1.
Failed to ensure a PRN medication order for an anti-anxiety drug (Lorazepam) was limited to 14 days and lacked physician documentation for continuation for Resident #2.
Report Facts
Resident census: 19
Residents reviewed for care plan deficiency: 5
Residents reviewed for PRN medication deficiency: 4
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Director of Nursing | Director of Nursing | Acknowledged deficiencies related to Resident #1's anticoagulant care plan and Resident #2's PRN Lorazepam order |
Inspection Report
Annual Inspection
Census: 22
Deficiencies: 8
Date: Feb 21, 2022
Visit Reason
The inspection was a recertification health survey conducted from 2/14/22 to 2/21/22 to assess compliance with federal regulations for nursing facilities.
Findings
The facility was found deficient in multiple areas including failure to complete background checks prior to hire, incomplete and untimely comprehensive care plans, lack of 24-hour CPR certified staff, failure to provide restorative services as required, insufficient RN coverage, improper use and monitoring of psychotropic medications, and failure to timely notify residents and families of COVID-19 positive cases.
Deficiencies (8)
Failed to complete a background check for 1 of 5 employees prior to hire.
Failed to develop and implement comprehensive person-centered care plans for 2 of 12 residents reviewed.
Failed to review and revise care plans timely for 2 of 12 residents, including after falls and medication changes.
Failed to ensure properly trained personnel certified in CPR were available 24 hours per day.
Failed to ensure staff provided and followed individualized restorative programs for 2 of 3 residents reviewed.
Failed to provide RN coverage for at least 8 consecutive hours a day, 7 days a week on 3 days in a 4 week period.
Failed to ensure PRN psychotropic medication order was limited to 14 days and lacked documented rationale for extension; failed to routinely monitor residents for adverse effects of antipsychotic medications.
Failed to notify residents, representatives, and families by 5 p.m. the next calendar day following occurrence of COVID-19 positive staff cases for 7 of 8 positive cases in January 2022.
Report Facts
Census: 22
Deficiency count: 8
RN coverage days missed: 3
COVID-19 positive staff cases: 8
COVID-19 positive staff cases not timely notified: 7
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff I | Certified Nurse Aide | Named in deficiency for lack of background check prior to hire |
| Director of Nursing | Director of Nursing | Interviewed regarding care plan deficiencies, CPR certification, restorative services, and psychotropic medication monitoring |
| Nursing Home Administrator | Administrator | Interviewed regarding background check policy, CPR certification, and RN coverage |
| Staff J | Registered Nurse, Restorative | Interviewed regarding restorative care services and documentation |
| Office Manager | Office Manager | Interviewed regarding background checks and COVID-19 family notification |
Inspection Report
Abbreviated Survey
Census: 19
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 12/7/20-12/8/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Census: 19
Deficiencies: 0
Date: Dec 8, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspections and Appeals on 12/7/20-12/8/2020.
Findings
The facility was found to be in compliance with CMS and Centers for Disease Control and Prevention (CDC) recommended practices.
Inspection Report
Abbreviated Survey
Census: 22
Deficiencies: 0
Date: Jun 11, 2020
Visit Reason
A COVID-19 Focused Infection Control Survey was conducted by the Department of Inspection and Appeals to assess the facility's compliance with CMS and CDC recommended practices for COVID-19 preparation.
Findings
The facility was found to be in compliance with CMS and CDC recommended practices to prepare for COVID-19.
Inspection Report
Annual Inspection
Census: 27
Deficiencies: 6
Date: Mar 5, 2020
Visit Reason
The inspection was conducted as the facility's annual health survey to assess compliance with federal regulations.
Findings
The facility was found deficient in several areas including grievance policy communication, dependent adult abuse training, safe resident transfers, provision of nourishing bedtime snacks, food service safety and sanitation, infection prevention and control, and catheter care practices.
Deficiencies (6)
Failed to make information on how to file a grievance and the grievance officer's contact information available to residents.
Failed to provide current dependent adult abuse training for one of five employees reviewed.
Failed to ensure one resident had a safe transfer using a gait belt as planned.
Failed to offer nourishing snacks to residents at bedtime consistently.
Failed to maintain a clean and sanitary kitchen and failed to ensure all dietary staff wore proper hair and beard restraints.
Failed to follow proper infection control practices for a resident with an indwelling catheter, including inadequate hand hygiene during catheter care.
Report Facts
Facility census: 27
Employees reviewed: 5
Residents referenced: 2
Employees mentioned
| Name | Title | Context |
|---|---|---|
| Staff A | Certified Nurse Aide | Named in deficiency related to lack of current dependent adult abuse training. |
| Staff B | Certified Nurse Aide | Named in deficiency related to improper catheter care and hand hygiene. |
| Staff C | Dietary Aide | Named in deficiency related to improper beard restraint during food service. |
| Staff D | Cook | Named in deficiency related to kitchen sanitation and cleaning practices. |
| Staff E | Named in deficiency related to inconsistent offering of bedtime snacks. | |
| Debra Haugen | Administrator | Signed the inspection report and acknowledged grievance officer information was not posted. |
| Director of Nursing | Acknowledged lack of knowledge about expired dependent adult abuse training and improper catheter care practices. | |
| Business Office Manager | Monitors dependent adult abuse training compliance. |
Report
Feb 21, 2022
Report
Mar 5, 2020
Report
Mar 21, 2019
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